Public mental health services in Southern China and related health outcomes among individuals living with severe mental illness

Background Although national policies in China are comprehensive and instructive, a wide disparity exists between different cities. The current status of public mental health services by region in China remains unclear. This study aimed to investigate policies related to public mental health services, the contact coverage of public mental health services and outcomes of service users. Methods A cross-sectional study was carried out in Southern China, between April 2021 and March 2022. Considering the geographical location, socioeconomic development levels, and prevalence of severe mental illness, four cities including Wuhan, Changsha, Guangzhou, and Shenzhen were selected. Relevant service providers were asked to report data on mental health policies and facility-related information, including mental health resources, registration rates of patients, management rates of patients, and medication rates of patients. Eligible patients were invited to report service user-related data, including contact coverage of public mental health services and their outcomes. SPSS 26.0 was used for data analysis. Results The four cities in Southern China have made different efforts to develop public mental health services, primarily focusing on socio-economically disadvantaged individuals. Community health centers in Guangzhou and Shenzhen reported having more professional human resources on mental health and higher mental health budgets for patients. The contact coverage rates of most public mental services were higher than 80%. Patients in Changsha (B = 0.3; 95%CI: 0.1–0.5), Guangzhou (B = 0.2; 95%CI: 0.1–0.3), and Shenzhen (B = 0.3; 95%CI: 0.1–0.4) who received social medical assistance services reported higher levels of medication adherence. Patients in Wuhan (B = -6.5; 95%CI: -12.9--0.1), Guangzhou (B = -2.8; 95%CI: -5.5--0.1), and Shenzhen who received community-based rehabilitation services reported lower levels of disability (B = -2.6; 95%CI: -4.6--0.5). Conclusions There have been advances in public mental health services in the four Southern cities. The contact coverage rates of most public mental health services were higher than 80%. Patients’ utilization of public mental services was associated with better health outcomes. To improve the quality of public mental health services, the government should try to engage service users, their family members, and supporters in the design, delivery, operationalization, and evaluation of these public mental health services in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s41256-024-00363-0.

Table S3 The tools used for measurement of different variables

Details of measurement
Disability [1] The WHODAS 2.0 as a general measure of functioning and disability in major life domains was used in this study.The WHODAS 2.0 was found to have high internal consistency (Cronbach's alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient:0.98).Items can be scored on a 5-point scale ranging from 1 = none to 5 = extreme/cannot do.The higher scores reflect greater disability.
Functioning [2,3] The Global Assessment of Functioning (GAF) was used to assess the patient's overall functioning and consists of one 100-point single item covering three major domains: social functioning, occupational functioning, and psychological functioning.The total score ranges from 1 to 100, with higher scores indicating higher overall functioning.Examples are given for each 10-level interval.
Quality of life [4] Quality of life was measured using the first two general questions from the 14-item World Health Organization Quality of Life Brief Scale (WHOQOL-BREF), which is widely used across the world.The first item asks: "How do you evaluate your quality of life in the past two weeks?" on a 5-point scale from 1-"very bad" to 5-"very good".The second item asks: "Are you satisfied with your health status for the past two weeks?" on a 5-point scale from 1-"very unsatisfied" to 5-"very satisfied".Both items were self-rated by participants, with the total score ranging from 1 to 10 and a higher score indicating better quality of life.
Psychiatric symptoms [5,6] The Brief Psychiatric Rating Scale (BPRS) was used to assess the psychiatric symptomatology, including different symptoms, such as positive symptoms, negative symptoms, and affective symptoms, etc.The 18-item version of the scale was used in this study.Items 1-10 are rated by the participant during an interview, while items 11-18 are rated by the researcher following observation of the participant.Each item is rated on a 7point scale anchored at 1=not present and 7=extremely severe.

Medication adherence [7]
Adherence to medication in the past months was assessed as follows: (1) Nearly every day.
(2) More than half the days.( 3) About half the days.( 4) Less than half the days.( 5) Not at all.

Economic burden of disease [8]
The family burden scale of disease (FBS) is a general questionnaire to measure the family burden of patients.There are 24 items in six dimensions in the FBS, which include family economic burden (six items), family daily activities (fix items), family entertainment activities (four items), family relationship (five items), physical health of family members (two items), and mental health of family members (two items).The first six items were used to economic burden of schizophrenia.The scale adopts three grades of 0-2, in which no burden has a rating of 0 and severe burden has a rating of 2. Reference Use and Endorsement of WeChat-Based mHealth Among People Living With Schizophrenia in China.Journal of Medical Internet Research, 2020.22(9).

7.
Gong, W.J., et al., The association between a free medicine program and functioning in people with schizophrenia: a cross-sectional study in Liuyang, China.Peerj, 2020.8.

8.
Pai, S. and R.L. Kapur, The burden on the family of a psychiatric patient: development of an interview schedule.Br J Psychiatry, 1981.138: p. 332-5.

Data Analysis Model
The associations between utilization

Note:
The program requires follow-up services and physical examination services for all patients under management, but the above four services were provided with restrictions.Therefore, when designing the questionnaire, we only asked the reasons for not using the above four services.

Inclusion process for the participants Table S2 inclusion criteria Policy/participants Inclusion criteria / Exclusion criteria Policies for public mental health services Inclusion criteria
a) work in the district mental health center; b) responsible for the work related to community mental health services Staff who reported policy-related data in each included primary health centers Inclusion criteria: a) work in the community health center; b) responsible for the work related to mental health services Exclusion criteria: none Individuals with schizophrenia Inclusion criteria: a) adults over 18 years of age; b) with a diagnosis of schizophrenia by ICD-10; c) able to read and communicate Exclusion criteria: a) Have epilepsy or severe head injury or serious head disease; b) have mental retardation Family caregivers of the individuals with schizophrenia Inclusion criteria: a) adults over 18 years of age; b) a family member who is living with the patient and has taken the most responsibility of caring; c) able to read and communicate Exclusion criteria: none

rate of community-based public mental health services and patient- related outcomes (n=972) Six different models were conducted for different outcomes
Patient-related covariates: gender, age, duration of schizophrenia, time under management, marital status, education level, family income, work status, living alone or not, location of residence, and geographical accessibility of service.